The importance of chronic sleep insufficiency is under-recognized as a public health problem, despite being associated with numerous physical and mental health problems, injury, loss of productivity, and mortality (1,2). Approximately 29% of U.S. adults report sleeping <7 hours per night (3) and 50--70 million have chronic sleep and wakefulness disorders (1). A CDC analysis of 2006 data from the Behavioral Risk Factor Surveillance System (BRFSS) in four states showed that an estimated 10.1% of adults reported receiving insufficient rest or sleep on all days during the preceding 30 days (4). To examine the prevalence of insufficient rest or sleep in all states, CDC analyzed BRFSS data for all 50 states, the District of Columbia (DC), and three U.S. territories (Guam, Puerto Rico, and U.S. Virgin Islands) in 2008. This report summarizes the results, which showed that among 403,981 respondents, 30.7% reported no days of insufficient rest or sleep and 11.1% reported insufficient rest or sleep every day during the preceding 30 days. Females (12.4%) were more likely than males (9.9%) and non-Hispanic blacks (13.3%) were more likely than other racial/ethnic groups to report insufficient rest or sleep. State estimates of 30 days of insufficient rest or sleep ranged from 7.4% in North Dakota to 19.3% in West Virginia. Health-care providers should consider adding an assessment of chronic rest or sleep insufficiency to routine office visits so they can make needed interventions or referrals to sleep specialists.

BRFSS* is a state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. civilian population aged ≥18 years, which is conducted by state health departments in collaboration with CDC (5). In 2008, response rates† among all 50 states, DC, and territories ranged from 35.8% to 65.9% (median: 53.3%), based on Council of American Survey and Research Organizations (CASRO) guidelines. Cooperation rates§ ranged from 59.3% to 87.8% (median: 75.0%).

The 2008 survey included the question, "During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?" Data from all sites were aggregated, and the numbers of days of perceived insufficient rest or sleep were categorized as zero days, 1--13 days, 14--29 days, and 30 days. Analyses were stratified by age group, race/ethnicity, sex, employment status, education level, marital status, and geographic area. Age-adjusted prevalence estimates were obtained and standardized to the projected U.S. 2000 population and 95% confidence intervals were calculated using statistical software to account for the complex sampling design. Age-adjusted estimates account for variations within state populations and permit comparisons between states and the 2006 report (4) examining data from four states. Statistical significance was determined by using t-tests. Unless otherwise indicated, all comparisons mentioned in this report were significant at the p<0.001 level.

Among the 403,981 adult respondents, an estimated 30.7% reported no days of insufficient rest or sleep in the preceding 30 days, 41.3% reported 1--13 days, 16.8% reported 14--29 days, and 11.1% reported 30 days (Table 1). The prevalence of adults reporting no days of insufficient rest or sleep in the preceding 30 days increased with age; persons aged ≥45 years were more likely to report no days than adults aged <45 years. Hispanic (38.8%) and other non-Hispanic racial/ethnic groups (35.4%) were more likely to report no days in comparison with non-Hispanic whites (27.9%) and non-Hispanic blacks (30.4%). Men (33.6%) were more likely to report no days than women (28.1%). Retired persons (43.8%) were most likely to report no days of insufficient rest or sleep in comparison with adults reporting other types of employment status (p=0.003). Those with less than a high school diploma or general education development certificate (GED) (37.9%) also were more likely to report no days of insufficient rest or sleep in comparison with those with a high school diploma or GED (33.8%) or with some college or college degree (28.0%). Finally, reports of no days of insufficient rest or sleep were similar among adults of varying marital status, although never married adults (31.6%) were more likely to report no days than members of an unmarried couple (28.4%; p=0.005).

The percentage of adults reporting insufficient rest or sleep every day during the preceding 30 days generally declined with age (Table 1). The percentage was highest among persons aged 25--34 years (13.8%) and lowest among persons aged ≥65 years (7.4%). Non-Hispanic blacks (13.3%) were significantly more likely than non-Hispanic whites (11.2%) to report 30 days of insufficient rest or sleep. Females were more likely to report 30 days of insufficient rest or sleep than males (12.4% versus 9.9%, respectively). Persons who reported being unable to work (25.8%) and unemployed respondents (13.9%) were significantly more likely to report 30 days of insufficient rest or sleep than respondents who were employed (9.9%), retired (9.5%; p=0.011), or a student or homemaker (11.1%). In comparison with persons with some college education or a college degree (9.6%), insufficient rest or sleep was significantly more likely to be reported by persons with less than a high school education (14.3%) and among those with a high school diploma or GED (13.2%). Compared with married respondents (11.1%), those who were divorced, widowed, or separated were more likely to report insufficient sleep (16.0%). Percentages for never married persons (10.6%) and members of an unmarried couple (12.1%) were similar to those for married adults (11.1%; p=0.139).

The distribution of reported days of insufficient rest or sleep varied among states and territories (Table 2). The lowest age-standardized prevalences of 30 days of insufficient rest or sleep in the preceding 30 days were observed in North Dakota (7.4%), California (8.0%), DC (8.5%), Wisconsin (8.6%), and Oregon (8.8%); the highest were observed in Puerto Rico (14.0%), Oklahoma (14.3%), Kentucky (14.4%), Tennessee (14.8%), and West Virginia (19.3%) (Figure).

Editorial Note:

This is the first published report to present state-based estimates of perceived insufficient sleep or rest by adults for the 50 states, DC, and three U.S. territories. The insufficient rest or sleep question was included on the 2008 BRFSS core questionnaire in response to an Institute of Medicine recommendation that CDC expand surveillance of population sleep patterns (1). The analysis presented in this report found that an estimated 11.1% of respondents reported experiencing insufficient rest or sleep every day for the preceding 30 days and 30.7% of respondents reported no days of insufficient sleep or rest, similar to the 10.1% and 29.6%, respectively, reported by adults from four states in 2006 (4). Racial/ethnic and sex differences observed in this 2008 study were not seen in the 2006 data and likely are the result of increased geographic representation in the sample population and a much larger sample size in 2008. However, the 2008 findings are consistent with previous research indicating a higher prevalence of self-reported frequent insufficient rest or sleep by women in comparison with men (6) and disparities in sleep duration reported by non-Hispanic blacks in comparison with whites (7,8).

The high prevalence of insufficient rest or sleep was concentrated in the southeastern United States. The causes of the geographic variations found cannot be determined by this study. However, geographic variations in occupational factors (e.g., shift work opportunities and extended work schedules) and lifestyle choices (e.g., use of technology), and the distribution of related common chronic diseases (e.g., obesity [9], depression, hypertension, heart disease, and stroke), many of which also are concentrated in the Southeast, might play a role and should be examined further (10).

The major causes of sleep loss are overlapping and include lifestyle and occupational factors that reflect broad societal factors (e.g., work hours and access to technology), and specific sleep disorders (1). Further studies are needed to explain the sex and racial/ethnic differences apparent in these results. Women are underrepresented in studies of sleep and sleep disorders (7). Further research also is needed to examine the relationship between sleep during pregnancy and postpartum and sleep-related diseases, such as depression, which are more prevalent in women (7). Racial and ethnic minorities disproportionately report sleep durations that are associated with increased mortality and might contribute to health disparities, and they are overrepresented in low socioeconomic environments that might compromise sleep quality (7). In this analysis, persons unable to work expressed the greatest prevalence of perceived rest or sleep insufficiency, which might be the result of mental distress or medical problems, disabilities, or other conditions that prevent them from being employed.

The findings in this report are subject to at least three limitations. First, the definitions of "enough (sufficient)" sleep and "rest" and responses to the survey question were subjective and were not accompanied by reports of hours of sleep per night; therefore, this analysis cannot be compared directly with studies of sleep duration. Because the survey question also did not distinguish between "rest" and "sleep," respondents might vary in their interpretation of the questions and the terms. Finally, institutionalized persons and persons residing in households without landline telephones are not included in the survey. Therefore, the findings of this report are not generalizable to those populations.

According to the National Sleep Foundation, adults need 7--9 hours of sleep each night. Health-care professionals should evaluate patients who report chronic insufficient rest or sleep and advise them of effective behavioral strategies including keeping a regular sleep schedule; avoiding stimulating activities within 2 hours of bedtime; avoiding caffeine, nicotine, and alcohol in the evening; sleeping in a dark, quiet, well-ventilated space; and avoiding going to bed hungry.¶ Pharmacologic intervention also might be warranted. Although few formal clinical practice guidelines are available for assessing and treating sleep insufficiency and sleeping disorders, a multidisciplinary team, including a sleep specialist, might be required for proper treatment (1).

Acknowledgment

The findings in this report are based, in part, on data provided by BRFSS state coordinators from the 50 United States, DC, Guam, Puerto Rico, and U.S. Virgin Islands.

References

Institute of Medicine. Sleep disorders and sleep deprivation: an unmet public health problem. Washington, DC: The National Academies Press; 2006.

A 2008 MMWR report of perceived insufficient rest or sleep by adults from four states using 2006 Behavioral Risk Factor Surveillance System (BRFSS) data found that 1 in 10 adults reported insufficient rest or sleep every day in the preceding 30 days and 29.6% reported no days of insufficient rest or sleep.

What is added by this report?

Insufficient rest or sleep prevalence estimates from adults in the 50 United States, the District of Columbia, and three U.S. territories (Guam, Puerto Rico, and U.S. Virgin Islands) from the 2008 BRFSS substantiate previous findings, add support for sex and race/ethnicity differences, and characterize geographic variations in the state-based reports of rest or sleep insufficiency.

What are the implications for public health practice?

Health-care providers should consider adding an assessment of chronic rest or sleep insufficiency to routine office visits so they can make needed interventions or referrals to sleep specialists.

TABLE 1. Age-adjusted* percentage of adults who reported insufficient rest or sleep† during the preceding 30 days, by number of days and selected characteristics --- Behavioral Risk Factor Surveillance System, United States,§ 2008.

Characteristic

No.¶

0 days

1--13 days

14--29 days

30 days

%

(95% CI**)

%

(95% CI)

%

(95% CI)

%

(95% CI)

Total

403,981

30.7

(30.4--31.0)

41.3

(41.0--41.6)

16.8

(16.6--17.1)

11.1

(10.9--11.4)

Age group (yrs)

18--24

13,881

23.2

(21.9--24.5)

45.5

(44.1--47.0)

19.7

(18.5--20.8)

11.6

(10.7--12.5)

25--34

38,978

21.8

(21.0--22.6)

44.1

(43.2--45.0)

20.4

(19.7--21.1)

13.8

(13.2--14.3)

35--44

61,350

22.8

(22.2--23.4)

45.2

(44.5--45.9)

20.1

(19.5--20.6)

12.0

(11.5--12.4)

45--64

169,906

30.5

(30.0--30.9)

42.4

(41.9--42.8)

16.3

(16.0--16.6)

10.9

(10.6--11.1)

≥65

119,866

56.7

(56.2--57.2)

28.3

(27.8--28.8)

7.6

(7.3--7.9)

7.4

(7.2-- 7.7)

Race/Ethnicity

White, non-Hispanic

318,694

27.9

(27.6--28.2)

42.7

(42.4--43.1)

18.2

(17.9--18.5)

11.2

(10.9--11.4)

Black, non-Hispanic

31,513

30.4

(29.4--31.3)

40.4

(39.3--41.5)

16.0

(15.1--16.8)

13.3

(12.6--14.0)

Hispanic

28,045

38.8

(37.7--39.9)

37.7

(36.6--38.8)

13.0

(12.3--13.8)

10.5

(9.9--11.2)

Other, non-Hispanic††

22,108

35.4

(34.0--36.7)

37.2

(35.8--38.6)

15.8

(14.8--16.8)

11.6

(10.8--12.5)

Sex

Male

152,513

33.6

(33.1--34.1)

40.9

(40.4--41.5)

15.6

(15.2--16.0)

9.9

(9.6--10.2)

Female

251,468

28.1

(27.7--28.5)

41.5

(41.1--41.9)

18.0

(17.6--18.3)

12.4

(12.1--12.7)

Employment status

Employed

215,127

28.7

(28.3--29.2)

44.2

(43.7--44.6)

17.1

(16.8--17.5)

9.9

( 9.7--10.2)

Unemployed

16,797

32.5

(31.0--34.0)

36.7

(35.2--38.2)

16.9

(15.8--18.0)

13.9

(12.9--14.9)

Retired

106,325

43.8

(36.4--51.3)

33.2

(25.7--40.7)

13.4

(9.7--17.2)

9.5

(6.2--12.8)

Unable to work

25,956

24.3

(22.6--25.9)

28.4

(26.5--30.2)

21.6

(20.2--23.0)

25.8

(24.3--27.3)

Other§§

38,395

31.3

(30.5--32.2)

41.7

(40.8--42.6)

15.9

(15.3--16.5)

11.1

(10.5--11.7)

Education

<High school diploma or GED¶¶

39,395

37.9

(36.7--39.0)

33.6

(32.5--34.8)

14.2

(13.5--15.0)

14.3

(13.5--15.0)

High school diploma or GED

121,346

33.8

(33.2--34.4)

37.3

(36.7--37.9)

15.7

(15.3--16.2)

13.2

(12.7--13.6)

Some college or college graduate

242,194

28.0

(27.7--28.4)

44.5

(44.0--44.9)

17.9

(17.5--18.2)

9.6

(9.4--9.9)

Marital status

Married

226,418

30.9

(30.3--31.5)

42.1

(41.4--42.7)

15.9

(15.5--16.3)

11.1

(10.7--11.6)

Divorced, widowed, separated

119,372

30.4

(29.1--31.7)

35.1

(33.7--36.4)

18.6

(17.5--19.6)

16.0

(14.9--17.1)

Member of unmarried couple

8,945

28.4

(26.3--30.5)

42.8

(40.5--45.0)

16.7

(15.2--18.2)

12.1

(10.9--13.3)

Never married

48,016

31.6

(30.8--32.4)

41.0

(40.2--41.9)

16.7

(16.1--17.4)

10.6

(10.1--11.1)

* Age adjusted to 2000 projected U.S. population.

† Determined by response to the question, "During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?"

§ Includes the 50 states, District of Columbia, Guam, Puerto Rico, and U.S. Virgin Islands.

¶ Unweighted sample. Categories might not sum to survey total because of missing responses.

** Confidence interval.

†† Asian, Hawaiian or other Pacific Islander, American Indian/Alaska Native, or multiracial.

§§ Homemaker or student.

¶¶ General Educational Development certificate.

TABLE 2. Age-adjusted* percentage of adults who reported insufficient rest or sleep† during the preceding 30 days, by number of days and state or area --- Behavioral Risk Factor Surveillance System, United States,§ 2008

0 days

1--13 days

14--29 days

30 days

State/Area

No.

%

(95% CI¶)

%

(95% CI)

%

(95% CI)

%

(95% CI)

Alabama

6,282

30.1

(28.4--31.9)

39.3

(37.3--41.2)

17.4

(15.7--19.0)

13.2

(11.9--14.5)

Alaska

2,557

32.2

(29.7--34.6)

41.1

(38.1--44.1)

17.3

(15.0--19.7)

9.4

(7.4--11.4)

Arizona

5,999

32.9

(30.2--35.7)

41.3

(38.4--44.2)

14.3

(12.2--16.3)

11.5

(9.3--13.6)

Arkansas

5,494

29.1

(27.4--30.7)

40.8

(38.8--42.7)

17.8

(16.3--19.3)

12.3

(10.9--13.8)

California

11,545

32.9

(31.8--34.1)

42.6

(41.3--43.8)

16.5

(15.6--17.4)

8.0

(7.3--8.7)

Colorado

11,465

31.2

(30.1--32.4)

43.0

(41.7--44.2)

16.6

(15.6--17.5)

9.2

(8.5--10.0)

Connecticut

5,957

28.5

(26.7--30.2)

45.4

(43.4--47.5)

15.7

(14.1--17.3)

10.4

(9.2--11.6)

Delaware

3,951

28.7

(26.8--30.6)

41.6

(39.2--44.0)

17.8

(15.9--19.7)

11.9

(10.4--13.5)

District of Columbia

4,095

31.4

(29.3--33.5)

44.3

(42.1--46.5)

15.8

(14.3--17.4)

8.5

(7.3-- 9.6)

Florida

10,542

33.5

(31.6--35.5)

38.0

(36.0--40.1)

14.9

(13.3--16.5)

13.5

(12.1--14.9)

Georgia

5,576

28.9

(27.2--30.5)

41.3

(39.3--43.2)

16.4

(14.9--18.0)

13.4

(11.9--14.9)

Hawaii

6,343

35.6

(34.0--37.2)

40.0

(38.3--41.8)

14.5

(13.2--15.8)

9.8

( 8.8--10.9)

Idaho

4,975

29.5

(27.9--31.1)

43.3

(41.3--45.3)

18.3

(16.7--19.9)

8.9

(7.9--9.9)

Illinois

5,106

26.7

(25.2--28.3)

45.1

(43.2--46.9)

18.4

(16.9--19.9)

9.8

(8.6--10.9)

Indiana

4,731

28.9

(27.0--30.7)

41.7

(39.5--43.8)

18.0

(16.4--19.7)

11.4

(10.0--12.8)

Iowa

5,846

30.2

(28.8--31.6)

41.8

(40.1--43.6)

16.9

(15.5--18.3)

11.1

(9.9--12.2)

Kansas

8,414

30.4

(29.2--31.7)

41.5

(40.0--42.9)

17.3

(16.1--18.5)

10.8

(9.9--11.7)

Kentucky

7,947

26.0

(24.6--27.5)

38.2

(36.4--40.1)

21.3

(19.6--23.0)

14.4

(13.1--15.7)

Louisiana

5,991

35.0

(33.4--36.7)

37.3

(35.6--38.9)

14.7

(13.4--15.9)

13.0

(11.9--14.1)

Maine

6,653

29.3

(27.9--30.6)

42.4

(40.7--44.1)

17.3

(15.9--18.6)

11.1

(10.0--12.3)

Maryland

9,299

28.6

(27.2--30.0)

42.8

(41.2--44.3)

18.5

(17.2--19.7)

10.1

(9.2--11.0)

Massachusetts

19,940

30.2

(29.2--31.2)

41.1

(39.9--42.3)

17.0

(16.1--17.9)

11.8

(11.0--12.6)

Michigan

9,198

28.6

(27.3--29.8)

43.3

(41.8--44.7)

17.4

(16.2--18.5)

10.8

(9.9--11.7)

Minnesota

4,271

29.4

(27.7--31.1)

44.7

(42.7--46.7)

15.9

(14.4--17.5)

10.0

(8.8--11.3)

Mississippi

7,715

32.4

(30.9--33.9)

37.2

(35.6--38.8)

17.3

(16.0--18.6)

13.1

(12.0--14.2)

Missouri

5,060

27.6

(25.9--29.3)

42.2

(40.1--44.3)

16.7

(15.2--18.3)

13.4

(12.0--14.9)

Montana

6,675

28.4

(26.8--30.0)

42.3

(40.4--44.2)

19.4

(17.8--20.9)

9.9

(8.7--11.1)

Nebraska

15,879

29.2

(27.8--30.5)

45.5

(43.9--47.2)

16.3

(15.2--17.5)

9.0

(7.9--10.0)

Nevada

4,670

30.8

(28.7--33.0)

40.5

(38.2--42.8)

17.5

(15.7--19.4)

11.1

(9.6--12.6)

New Hampshire

6,729

27.6

(26.2--29.0)

44.8

(43.1--46.6)

17.7

(16.3--19.2)

9.9

(8.8--10.9)

New Jersey

11,333

32.2

(30.9--33.6)

39.8

(38.4--41.3)

15.1

(14.0--16.2)

12.8

(11.8--13.8)

New Mexico

6,139

33.2

(31.4--34.9)

40.5

(38.6--42.4)

15.7

(14.3--17.2)

10.6

(9.5--11.7)

New York

7,614

28.7

(27.2--30.1)

42.8

(41.2--44.4)

17.8

(16.6--19.1)

10.8

(9.8--11.7)

North Carolina

15,426

31.9

(30.8--33.0)

39.0

(37.8--40.3)

16.0

(15.1--16.9)

13.0

(12.2--13.9)

North Dakota

4,879

29.4

(27.9--31.0)

47.1

(45.3--49.0)

16.0

(14.7--17.4)

7.4

(6.5--8.4)

Ohio

12,651

27.1

(25.9--28.2)

42.7

(41.3--44.1)

18.7

(17.6--19.9)

11.4

(10.5--12.4)

Oklahoma

7,658

30.8

(29.4--32.2)

37.5

(35.9--39.0)

17.4

(16.3--18.6)

14.3

(13.2--15.3)

Oregon

4,691

28.4

(26.7--30.1)

48.7

(46.7--50.8)

14.1

(12.6--15.5)

8.8

(7.6--9.9)

Pennsylvania

12,770

29.8

(28.4--31.1)

40.3

(38.7--41.8)

18.6

(17.3--19.9)

11.3

(10.4--12.3)

Rhode Island

4,676

29.6

(27.9--31.3)

42.7

(40.7--44.8)

16.8

(15.2--18.3)

10.9

(9.7--12.1)

South Carolina

9,799

32.7

(31.0--34.3)

40.8

(39.0--42.6)

14.5

(13.3--15.8)

12.0

(10.8--13.2)

South Dakota

6,796

32.2

(30.7--33.8)

41.8

(40.0--43.6)

14.5

(13.3--15.8)

11.5

(10.2--12.7)

Tennessee

4,882

32.0

(29.7--34.2)

36.8

(34.4--39.2)

16.4

(14.6--18.3)

14.8

(13.2--16.3)

Texas

10,432

32.7

(31.2--34.1)

39.8

(38.2--41.4)

15.8

(14.6--17.0)

11.8

(10.7--12.8)

Utah

5,187

25.6

(24.2--27.0)

46.7

(44.9--48.5)

18.5

(17.2--19.9)

9.2

(8.1--10.2)

Vermont

6,586

27.3

(26.1--28.6)

45.2

(43.6--46.8)

17.8

(16.4--19.1)

9.7

(8.7--10.7)

Virginia

5,150

29.5

(27.0--32.0)

41.9

(39.4--44.5)

18.7

(16.5--20.9)

9.9

(8.7--11.0)

Washington

22,096

29.0

(28.1--29.9)

42.9

(42.0--43.9)

18.2

(17.4--19.0)

9.9

(9.2--10.5)

West Virginia

4,073

27.6

(25.9--29.3)

33.8

(31.9--35.8)

19.3

(17.7--20.8)

19.3

(17.6--21.0)

Wisconsin

6,989

28.0

(26.3--29.6)

44.5

(42.4--46.5)

18.9

(17.2--20.7)

8.6

(7.5--9.7)

Wyoming

7,814

28.6

(27.4--29.7)

44.1

(42.6--45.5)

17.3

(16.2--18.4)

10.1

(9.2--11.0)

Guam

766

46.1

(42.1--50.1)

34.8

(31.0--38.5)

7.7

(5.9--9.6)

11.4

(8.8--14.0)

Puerto Rico

4,353

50.7

(48.8--52.7)

24.9

(23.2--26.6)

10.3

(9.1--11.5)

14.0

(12.7--15.4)

U.S. Virgin Islands

2,316

35.5

(33.1--37.9)

41.8

(39.2--44.4)

13.1

(11.3--14.9)

9.6

(8.0--11.2)

Total

403,981

30.7

(30.4--31.0)

41.3

(41.0--41.6)

16.8

(16.6--17.1)

11.1

(10.9--11.4)

* Age adjusted to 2000 projected U.S. population.

† Determined by response to the question, "During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?"

§ Includes the 50 states, District of Columbia, Guam, Puerto Rico, and U.S. Virgin Islands.

¶ Confidence interval.

FIGURE. Age-adjusted* percentage of adults who reported 30 days of insufficient rest or sleep† during the preceding 30 days --- Behavioral Risk Factor Surveillance System, United States,§ 2008.

* Age adjusted to 2000 projected U.S. population.

† Determined by response to the question, "During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?"

§ Includes the 50 states, District of Columbia, Guam, Puerto Rico, and U.S. Virgin Islands.

Alternative Text: The figure above shows the age-adjusted percentage of adults who reported 30 days of insufficient rest or sleep during the preceding 30 days in the United States in 2008. The lowest age-standardized prevalences of 30 days of insufficient rest or sleep in the preceding 30 days were observed in North Dakota (7.4%), California (8.0%), District of Columbia (8.5%), Wisconsin (8.6%), and Oregon (8.8%); the highest were observed in Puerto Rico (14.0%), Oklahoma (14.3%), Kentucky (14.4%), Tennessee (14.8%), and West Virginia (19.3%).

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